Prior to the ACA most states had little or no restrictions on insurance rates taking account of enrollees’ health risks. In the 1990s a small number of states imposed community rating and guaranteed issue in their health insurance markets, as the ACA has done, but without any subsidies, exactly the same situation that will result on the federal exchanges from a plaintiffs’ victory in King v. Burwell. It was widely predicted these states would experience an adverse selection death spiral. A 1999 National Bureau of Economic Research (NBER) paper by Thomas Buchmueller and John Dinardo compared New York, which had imposed community rating and guaranteed issue, with neighboring states. They “found no evidence for the conventional wisdom that the imposition of pure community rating tends to an adverse selection death spiral.” Similarly, another 2006 NBER paper by Bradley Herring and Mark V. Pauly compared states with community rating and guaranteed issue to states with no such regulations. They found a small increase in the number of uninsured, but did “not observe a strong positive relationship between risk status and the likelihood of being covered, that would be consistent with so-called death spirals.”

This session was especially helpful to congressional staff members new to the issue, but is also a useful review for anyone dealing with the Affordable Care Act (ACA). The briefing took place just as the second marketplace enrollment period ended and the Supreme Court heard oral arguments in a case challenging the law’s subsidies.

What are the key provisions of the ACA? How did the ACA extend coverage to the uninsured? How does the ACA impact private and public insurance coverage, marketplaces and employer-sponsored coverage? What is the role for states? What are the requirements on employers and individuals? How was Medicaid changed by the ACA and then the Supreme Court? How is the Children’s Health Insurance Program (CHIP) affected?

Everything in the legislative history that sheds light on what Congress intended supports the plain meaning of the language limiting premium subsidies to those who obtain coverage “through an Exchange established by the State.”

The lead author of the ACA, then-Senate Finance Committee Chairman Max Baucus, D-Mont., had proposed — and even gotten Congress to enact — other health-insurance tax credits and subsidies that were conditioned on states taking certain actions.

Senate Democrats similarly considered letting individual states opt out of the Democrats’ cherished “public option.”

Congressional Democrats considered other bills in 2009 that explicitly did authorize subsidies in federal exchanges. But they discarded that language in favor of the ACA’s approach.

More than a dozen Senate Democrats championed a bill that explicitly conditioned exchange subsidies on states implementing that bill’s employer mandate. Those senators discarded that condition in favor of the ACA’s approach of explicitly conditioning premium subsidies on states implementing exchanges.

Eleven House Democrats from Texas recognized and even complained that states could prevent their residents from receiving “any benefit” under the ACA, including premium subsidies, simply by refusing to establish exchanges. In early January 2010, they pleaded for House Speaker Nancy Pelosi and President Barack Obama to support one of the bills that explicitly authorized subsidies in federal exchanges. Yet all 11 of them ended up voting for the ACA, despite their reservations.

One of the ACA’s architects and a paid consultant to the Obama administration, Massachusetts Institute of Technology health economist Jonathan Gruber, repeatedly described the ACA by saying: “If you’re a state and you don’t set up an exchange, that means your citizens don’t get their tax credits.”

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We are walking a psychological tight rope here. Public support for combating obesity depends in part on helping people understand that obesity is not simply the result of lazy behavior, but is also influenced by a range of social and even physiological forces beyond people’s complete control. Reduction of stigma also depends on helping people understand that obesity is not simply a lifestyle choice.

But the better we succeed in convincing people that obesity is a disease, the less motivated obese people will be to fight back against these social and physiologic forces.

This all suggests that the vast majority of the post-recession slowdown is attributable to lower economy-wide price inflation along with some temporary noncyclical factors. Of the surprisingly small amount left to be explained by the recession and structural changes, I would attribute the greatest share to the recession.

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Taken together, the administrative data tell us that the number of Americans with health insurance coverage increased by around 9.7 million individuals during 2014—not the 14.1 million estimated by Health and Human Services.

The number of Medicaid-enrolled patients with newly identified diabetes increased by 23% (14,625 vs. 18,020 patients) in the 26 states (and District of Columbia) that expanded Medicaid compared with an increase of 0.4% (11,612 vs. 11,653 patients) in the 24 states that did not expand Medicaid during this period. Similar differences were observed in younger and older adults and for both men and women.

CONCLUSIONS This study suggests that in the states that expanded Medicaid under the ACA, an increased number of Medicaid patients with diabetes are being diagnosed and treated earlier. This could be anticipated to lead to better long-term outcomes.